ARTHROSCOPY - SURGICAL-INTERVENTIONS

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Arthroscopy

Generality

Arthroscopy is a surgical procedure which diagnoses and treats the most important joint disorders of the human body. It is characterized by minimal invasiveness combined with great safety and efficacy.

Its execution involves the use of various instruments, including the arthroscope. This is the most important surgical "iron", because it allows you to illuminate the joint cavity and film what happens inside it.
Preparation for arthroscopy requires the patient some simple precautions, which however must be followed to the letter, if the operation is to be successful.
The healing times depend on the seriousness of the joint damage and on the attention that the patient himself has towards himself, during the recovery phase.

What is arthroscopy?

Arthroscopy is a minimally invasive surgery that is performed to diagnose and treat joint disorders in the human body.
The operation involves the use of a particular instrument, called an arthroscope, inserted into the so-called joint cavity through a small (maximum one centimeter) skin incision. Sometimes, this incision is accompanied by others: in fact, in certain situations, more than one are required in order to insert the operating tools necessary for the intervention.
The joints most subjected to arthroscopy are the most important in the body, also in terms of size, namely: knees, hips, shoulders, elbows and wrists.
Thanks to its minimal invasiveness, "arthroscopy is considered an example of" closed "surgery, as opposed to the classic (more invasive and risky)" open "surgery.

COM "IS THE ARTHROSCOPE DONE?"

The arthroscope is the main and most representative instrument of arthroscopy. Comparable in length and width to a drinking straw, it has, at the end to be inserted into the joint cavity, a network of optical fibers, which act as both a light source and a camera.
What is illuminated and captured by the arthroscope is projected onto a monitor (to which it is obviously connected), allowing the surgeon to orient himself within the joint and perform the operation correctly.

THE JOINTS

A joint is a complex anatomical structure which, by putting two or more neighboring bones in contact, allows them to move without direct contact and avoiding the wear that would ensue.
joint mobility; these elements are:

The tendons. Made up of very resistant fibrous tissue, they connect the muscles to the bones and help stabilize the joint.
The ligaments. Very similar in composition to tendons, they connect adjacent bone structures.
The cartilage structures. Made up of resistant connective tissue, they cover the surface of the bones involved in the joint. They are used to absorb shocks, reduce friction and prevent possible bone damage.
Synovial fluid. It is a thick and sticky fluid, which, being in the joint cavity and in contact with other structures, acts as an internal lubricant and a nutritional element for the carttilage. The liquid is enclosed within the so-called synovial membrane.

Without the joints, it would not be possible to bend the legs, extend the arms, lift objects, take a run etc.

When you do

At one time, when certain instruments were not yet available, arthroscopy was a purely diagnostic procedure, aimed at planning open surgery. Subsequently, with the advent of new devices and with the advances in medical technology, arthroscopy also assumed a therapeutic purpose. Today, thanks to the enormous experience acquired by orthopedic surgeons in this field, it has become one of the most common operations for the treatment of joint damage.

ARTHROSCOPY AS A DIAGNOSIS

Currently, diagnostic arthroscopy is performed when classic radiological examinations, such as magnetic resonance imaging (MRI), CT scan, or X-rays, do not clearly show the discomfort of a painful, stiff, swollen and / or snapping joint.
In other words, it represents a solution to uncertain cases, for which it is difficult to establish a definitive diagnosis.
Once the exact joint problem is outlined, arthroscopy can become therapeutic even during the same session.

ARTHROSCOPY AS THERAPY

During a therapeutic arthroscopy operation, the following operations can be performed:

Repair damage to cartilage, tendons or ligaments
Remove inflamed tissue. This is the case, for example, of the synovial membrane, which can become inflamed and lead to a synovitis.
Remove a small piece of bone or cartilage tissue, which, by breaking, has stiffened the joint.
Drain some of the synovial fluid when it is in excess.

WHICH PATHOLOGICAL CONDITIONS CAN BE CURED?

The pathological conditions that generally require arthroscopy are:

Osteoarthritis or osteoarthritis. It is a chronic degenerative disease of the joints, which causes inflammation, pain and joint stiffness.
Baker's cyst. Its appearance is due to an accumulation of synovial fluid in a certain point of the joint. It causes swelling and joint stiffness.
The so-called frozen shoulder. Patients who suffer from it complain of pain, limitation of movement and joint stiffness.
The temporomandibular disorders. These are disorders that affect the joint between the lower part of the mandible (lower jaw) and the temporal bone of the skull.
Arthrofibrosis. This is the generally post-traumatic formation of scar tissue within the joint. This tissue limits normal joint movement.
The synovitis. They are the inflammations of the synovial membrane, inside which the synovial fluid is contained.
The rupture of ligaments, tendons and menisci. The rupture of one of these structures is usually due to a sports trauma, but it can also occur during particularly heavy work or during a domestic accident.
The bony protuberances. They are neoformations of bone tissue, developed in a completely abnormal way and for no precise reason.

Preparation

A few days before the arthroscopy, the patient must go to the clinic, where the operation will take place, to undergo a series of cognitive clinical examinations and to be informed about the procedures and all the pre-operative measures to be taken.

PRE-OPERATIVE CLINICAL EXAMINATIONS

By subjecting the patient to a thorough physical examination, a complete blood test and an evaluation of the medical history (past illnesses, allergies to drugs and anesthetics, medications taken, etc.), it is established whether or not the required health conditions are present. for a good result of the intervention.

INFORMATION ON THE METHODS OF THE TRANSACTION

Once the pre-operative clinical examinations have been completed, the patient is informed about what the intervention involves, what is the duration of the entire procedure, what is the expected anesthesia, what are the rehabilitation exercises to be carried out at home and, finally, , how long the healing phase usually lasts.
If there are still doubts or fears, the medical staff is at the complete disposal of the patient for any other information.

PRE-OPERATIVE MEASURES

In order for the entire operation to proceed smoothly, the pre-operative measures must be followed to the letter. Also illustrated at the end of the clinical examinations, they consist of:

Present complete fasting for at least the previous evening, as anesthesia is required.
Be accompanied home by a family member or friend, because, after the surgery, you are certainly not self-sufficient. Driving is not allowed and it is very likely that you may feel confused due to the anesthesia.
Stop taking certain medications if they are in any way contraindicated.

Procedure

Arthroscopy is an outpatient surgery, which generally takes place in half a day and, with some exceptions, does not require hospitalization.
The operation is performed by inserting an arthroscope inside the joint, viewing the state of the joint cavity on a monitor and intervening where necessary.

Figure: A "real-time image of a meniscectomy.

The entire operation requires that the patient be anesthetized and sedated. Anesthesia can be general, local or spinal, according to the patient's characteristics (age, allergies to anesthetics, etc.) and according to the wishes of the operating surgeon.

ANESTHESIA

Local anesthesia. By local anesthesia, it is meant that the sense of "falling asleep" is limited to the joint to be operated on. The anesthetist, who is a specialized doctor, administers to the patient, in addition to the anesthetics, painkilling drugs and sedatives. Anesthetics and painkillers are injected near the painful area, while the sedatives are introduced intravenously. The effects are sufficiently powerful and lasting, so much so that the operated subject does not perceive any discomfort.

After the operation and the anesthesia has disappeared, the patient needs a few hours to recover.
Spinal anesthesia. Spinal anesthesia is practiced when the surgeon has to operate on the lower limbs. Anesthetics are injected near the spinal cord (therefore on the back), while painkillers are infused intravenously.
Once the operation is over and the effects of the anesthesia have disappeared, it takes a few hours to fully recover.
General anesthesia. General anesthesia is used if there is any contraindication to other types of anesthesia or by express will of the surgeon.
The anesthetic drugs, which are injected intravenously before and throughout the procedure, render the patient completely unconscious.
At the end of the operation, the pharmacological infusion is interrupted, so that the patient awakens. The total recovery of the senses and motor skills could take up to a whole day, therefore the patient could be invited to spend a night in the hospital.

ARTHROSCOPY

Once the anesthesia has taken place, the actual arthroscopy begins.
First, the surgeon covers the entire area to be operated with disinfectant, in order to minimize the risk of infection.
After that, he makes a first incision, about one centimeter, and puts the arthroscope in it.
With this instrument, he views the joint and explores the entire joint cavity.
Once he has orientated himself and identified the site of the problem, he makes other incisions, always of about one centimeter, and inserts the tools for repairing the joint damage.
When he considers the arthroscopic intervention concluded, he removes the surgical "tools", including the arthroscope, and closes the incisions with usually absorbable sutures.
If the anatomical area operated allows it, a compression bandage is also applied, which limits the natural post-operative swelling.

DURATION OF THE INTERVENTION

Figure: knee arthroscopy.

The duration of an arthroscopy depends on what the operation involves.
The simplest interventions can also be completed in 15-30 minutes; the more complex ones, on the other hand, can take from 45 to 120 minutes.

Post-operative phase

Immediately after the operation, the patient is taken to a comfortable hospitalization room of the clinic (or hospital) and kept under observation until the main effects of the anesthesia disappear. Only at this point, in fact, the surgeon gives the green light for discharge.
If general anesthesia is used, it is advisable for the operated person to spend the entire night in the hospital for completely precautionary reasons.

HOW DOES IT FEEL?

The after effects of anesthesia Tiredness, confusion, dizziness and lightheadedness are the main effects of anesthesia. They fade within a few hours, but for their complete resolution it is necessary to wait up to 24 hours. It is precisely for this reason that it is very important to be accompanied and assisted by a family member or friend.
The after-effects of the surgery. In the first few days, it is very likely that the operated area is painful and swollen. Pain and swelling should not alarm (unless they extend beyond the doctor's instructions), as they are two completely normal consequences , due to the incisions and the introduction of surgical instruments into the joint.

What care must be taken when washing?
One of the most frequently asked questions by patients is what to do when washing. Generally, the advice given by doctors is this: for the first 10 days, the wound should not be wet, as it could be contaminated with one or more colonies of bacteria. Therefore, it is good to cover the operated area with waterproof material and make sure that the water does not filter into it in any way. It may be useful to "wash in pieces".

REMEDIES FOR PAIN AND SWELLING

To relieve the painful sensation and swelling, it is useful:

Take pain relievers. The most used are paracetamol and, if there are no contraindications (allergies or risk of bleeding), aspirin.
Make ice packs. Ice works against pain and swelling. It is a natural remedy, very effective and, when used correctly, free from side effects. At least for the first week, it should generally be applied 4-5 times a day, for no more than 20 minutes.
Rest. Not getting tired accelerates the disappearance of pain and swelling.
If a lower limb has been operated on, keep the affected leg elevated. This is a great remedy for limiting swelling.

REHABILITATION EXERCISES TO BE CARRIED OUT AT HOME

In some cases, the doctor may advise the patient to carry out very simple rehabilitation exercises at home before the actual physiotherapy. It involves stretching to limit muscle stiffness, typical of the post-operative phase.

Recovery times

Recovery times basically depend on four factors:

The type of intervention. For example, anterior cruciate ligament reconstruction of the knee has a much longer prognosis than a meniscectomy, which is the removal of a small piece of torn meniscus.
The characteristics of the patient (age, state of health, etc.).
The work carried out by the patient. Those who perform sedentary work stress the operated joint less than those involved in heavy work; consequently, it heals sooner.
The attention that the patient has towards himself. This means, in other words, not neglecting the doctor's advice, not rushing ahead, entrusting himself to a physiotherapist, requesting a medical consultation if unusual pains appear, etc.

PERIODIC CHECKS

The post-operative checks are used by the attending physician to monitor the progress of the situation and to make sure that everything is going well.
Their number depends on the severity of the operation. For example, arthroscopic meniscectomy, which is a relatively simple operation with a rather short prognosis, involves a first check-up one week after surgery and a second check-up one month. from the intervention.

PHYSIOTHERAPY

Physiotherapy is essential to regain normal joint mobility. Therefore, after a few days from the operation, it is good to contact a trusted physiotherapist and begin to follow his instructions to the letter. postural and other disorders of a different nature.

RETURN TO THE € DAILY ACTIVITIES AND THE € SPORTS ACTIVITY

The return to daily activities, such as driving cars, and to sports activities depends on the type of surgery and the severity of the joint damage, which was remedied by arthroscopy.
The only advice that can be provided here is to undergo post-operative checks and consult, from time to time, with your doctor.
Making autonomous decisions could be risky and compromise the success of the arthroscopic surgery.

Risks and complications

Thanks to advances in medicine, arthroscopy is a safe procedure.
The risk of complications, in fact, is very low, so much so that according to an English statistic it concerns one case out of 100. Furthermore, in most cases, these are only temporary disorders, which resolve with a longer than expected prognosis.
The possible complications are as follows:

Internal haemorrhage in the joint. The loss of blood inside the operated joint causes joint pain and swelling. If the patient is promptly referred to the attending physician, it is a problem that can be solved without particular repercussions.
Internal joint infection. This disorder, also called septic arthritis, is due to bacterial contamination and causes joint pain and swelling. As in the case of bleeding, if the patient seeks immediate medical attention, it can be remedied.
Deep vein thrombosis. It is the formation of a blood clot in a vein that crosses the operated limb. The typical symptoms are swelling and pain. This is a very rare phenomenon, but which must be remedied quickly, because it is potentially dangerous.
Nervous damage. The surgeon can inadvertently damage the passing nerves in the vicinity of the joint, causing a certain loss of sensation. Today, thanks to the experience acquired by doctors and medical technology, this happens very rarely.